Chronic Back Pain: Hands-On Treatments and Mind-Body Techniques

The spine is essential to the way we stand and move, yet it causes so many of us to suffer.

By some estimates, at any given moment, 20 percent of the American population is experiencing some degree of lower-back discomfort; over the course of a lifetime 8 out of 10 of us will have been laid low with at least one bout of back pain. And the fix isn't usually as easy as a quick operation or a round of meds.

Part of the problem is that in 85 percent of cases, doctors have no idea what actually causes the pain, according to a 2001 New England Journal of Medicine report.

In the absence of a fail-safe medical or surgical solution to routine back pain, scores of alternative therapies have come to the fore. Curious mainstream researchers have set out to discover just how well they work, and at a more fundamental level, how they work.

For doctors like Nathaniel Tindel, a spine surgeon at Lenox Hill Hospital in New York City, if a patient has excruciating back pain and alternative therapies may help, he asks, "Why not use them?"

Hands-On TreatmentsThe intense sensation of someone working on your back while you rest on a table can be the most palpable proof that something good and healing is going on. For some back pain sufferers, the nurturing comfort of human contact is as therapeutic as the treatment itself.

ChiropracticFounded in the 1890s, chiropractic labored under the disadvantage that its foundational theory -- that a misaligned spine is the root of most medical problems -- couldn't be scientifically proven.

But after scorning it for more than a century, medical science has gotten wise to the fact that chiropractic manipulations can be an effective treatment for joint pain, especially chronic back pain.

In a landmark 2007 article, the American Pain Society and the American Society of Physicians reviewed the recent research and recommended spinal manipulation for acute low back pain that persists longer than a month.

A new generation of chiropractors is trying to figure out exactly how sharply twisting the spinal column can reduce back pain.

One current theory, explains Partap Khalsa, Ph.D., a chiropractor and biomedical research scientist, is that introducing a jolt of movement to the spine stimulates neurons in the surrounding tissues, sending a message up the spinal cord to the brain and ultimately resulting in pain reduction.

AcupunctureIn one of the biggest and most ambitious studies of its kind, published in 2009 in the Archives of Internal Medicine, acupuncture was found to improve back pain more than standard care that relied on medication and physical therapy. The catch: It didn't seem to matter what form of acupuncture was used.

Even so-called simulated acupuncture -- a toothpick in a tube that never penetrated the skin -- delivered results that rivaled the Traditional Chinese Medicine version. The study raises the possibility, Khalsa says, that acupuncture works because the therapeutic intervention may stimulate the release of feel-good endorphin neurochemicals -- involving a placebo (or "nonspecific") effect.

Trigger Point TherapiesPioneered by Janet Travell, M.D., served as a personal physician to Presidents Kennedy and Johnson, trigger point therapy evolved in a few directions, including hands-on therapy, most often used by massage therapists, and needling therapy, used by M.D.'s and musculoskeletal specialists.

Both styles zero in on myofascial trigger points -- hard, tender knots of muscle. The manual therapist finds the knots by touch and typically presses down on them hard for about 10 seconds with the thumbs, causing the muscles to release and the pain to lessen or disappear.

With needling, the practitioner finds the knots the same way but lightly taps them with a thin needle (with or without an anesthetic), causing the contracted muscle fibers to twitch rapidly.

For reasons thought to relate to the communication between the muscle fibers and the nervous system, it delivers a therapeutic punch.

"If you hit the right spot," says Jay P. Shah, M.D., a leading physiatrist at the National Institute of Health, "you feel an immediate softening of that muscle and the patient experiences a reduction in pain."

There aren't clear studies that show how it works, but Shah's research has proved trigger points are visible with ultrasound technology and that painenhancing biochemicals build up around them.

ARTActive Release Techniques (ART), one of the most popular forms of targeted or therapeutic massage, was developed by Colorado sports chiropractor P. Michael Leahy, who brought his approach to elite athletes.

Working by feel, an ART therapist finds areas of tense, contracted tissue, guides the patient to move her body in a way that puts the area under maximum muscular tension (that's the active part), then bears down with the thumbs.

Both ART and trigger point therapy effect a muscular release, but ART explains the therapeutic result at the level of the damaged tissue itself.

The theory, not yet lab tested, is that the precisely directed thumb pressure helps break up microscopic scar tissue that impedes the smooth movement of muscle fibers and can free peripheral nerves that get trapped between stuck muscles.

Mind-Body TechniquesThese methods are all about self-reliance: While a teacher guides you at the beginning, once you're comfortable with them, they'll be at your disposal. You can do the work yourself anytime without relying on a therapist.

Alexander TechniqueSomatic education therapies like Alexander are about how to skillfully move the body through life while putting as little stress as possible on the muscles and joints. The single biggest question that Alexander Technique teachers investigate with their students is how best to balance the head.

"We always start with the relationship of the head to the neck," says Jessica Wolf, a veteran Alexander teacher who runs the Art of Breathing studio in New York City.

If the head isn't properly balanced, the cervical spine will compress, sending unhappiness down to the lumbar spine and the hips, all the way to the feet. "Look for ease and balance" is an instruction you may hear often in an Alexander class.

A large, randomized controlled study, published in the UK in 2008, vouched for its effectiveness in reducing back pain in almost 600 sufferers.

"This was a pretty strong shot in the arm in terms of, Hey, here's something else that could be effective," Khalsa says.

Feldenkrais MethodSimilar to the Alexander Technique, Feldenkrais has the overarching goal of bringing awareness to bear on everyday movement, erasing years of bad habits born of injury, ergonomically challenged work environments, and psychological distress.

Moshe Feldenkrais and his disciples developed more than a thousand exercises, all emphasizing slow, small, gentle movements covering the range of human motion.

"With chronic back pain, the problem is often not the back but the way the whole body is organized to move," says David Zemach-Bersin, director of New York City's Feldenkrais Institute. "If we help that, the symptoms will improve or disappear."

According to Feldenkrais theory, when the student performs an exercise, she introduces her nervous system to this more efficient motion for use in daily life -- for instance, how best to turn the head to one side or how to stand without overstressing certain back muscles.

"We create the conditions for learning," Zemach-Bersin says. You and your nervous system do the rest." The method has been researched but is not yet supported by any major controlled studies.

Therapeutic YogaAt least six well-controlled studies have found that yoga eases back pain; one from an Indian team, published two years ago in The Journal of Alternative and Complementary Medicine, found yoga to be more effective than standard physical therapy-style stretching and strengthening exercises.

According to Lindsey Clennell, a yoga instructor and private yoga therapist in New York City, the physical benefits of guiding people into poses are real, but ultimately he sees himself as attending to the emotional stress that is kept locked in his students' bodies. "It's just more direct and easier to work at on the physiological level."

Mindfulness-Based Stress ReductionThe point of MBSR is to get people to be present with their pain, whether it's physical or emotional, explains Melissa Blacker, associate director of the Stress Reduction Program at the University of Massachusetts Medical School's Center for Mindfulness in Medicine, Health Care, and Society in Worcester.

"By being aware of the pain and not trying to fix it, the extra stuff -- the pain of not wanting the pain to be there -- disappears," she says.

In a series of large-scale studies published in the 1980s, the program's founder, Jon Kabat-Zinn, Ph.D., discovered that chronic-pain sufferers coped better emotionally with their pain after the MBSR course, but interestingly, the intensity of the sensation itself was unchanged.

In 2007, however, researchers from the University of Montreal looked at a small group of longtime Zen meditators and found they were less sensitive to pain than a matched group of nonmeditators.

This year the same lead author published another study that looked at MRI scans of meditators and found they had thicker brain tissues in the region of the cortex involved in the processing of pain.